What’s going on?

I talk a lot with different physicians about integrating NP/PA providers into their practice.  I am frequently astonished by the level of reluctance, resistance and downright animosity from these physicians.  Many times a doctor will have a medical “horror story” with the NP/PA  playing  the  villain.  One bad encounter or event seems to  justify a complete rejection of the many positive attributes and contributions of these NP/PA providers, and negates the many studies that reveal comparable and safe care and outcomes.  Besides I have a few “horror stories” of my own, and guess who the villains are?

I’m always mystified by this.  I practice in a very supportive environment.  This culture extends from the hospital leadership, both medical and nursing, which seems to understand what we do and values the care we provide, to my section leadership, to the consulting services, to the RNs I work with and most of all, to the patients to whom I provide this care.  Rarely if ever do I get a “I need to talk to your attending” type interaction, or get a request to see a physician.  But it hasn’t always been this way.  Our program is very mature and it is easy to forget the bumps and bruises I, and all of my NP/PA colleagues, have experienced on this road.  And I’ve had other clinical experiences, in other institutions, where I have had to swallow my outrage and anger at being treated like a second class citizen, or as a handmaiden, or worse, as a brainless robot acting completely on someone else’s orders.

But still I wonder:  Why in this day and age does this type of attitude persist?  Again, if you look at our numbers, we are here.  We aren’t going anywhere.  Our impact is only growing.  And it doesn’t sound to me like this is only a territorial issue-despite the persistent positions of the AMA.

Whenever there are “issues” in a relationship, personal or professional, I’m a firm believer in a two party system.  Rarely are these problems completely one-sided.  We all have our part to play.  And NP/PAs have a responsibility, a role  in some of the long standing difficulties that sometimes exist with our physician colleagues.  Check out this list:

1.  Shift worker mentality: Ever since a doctor was toddling around in his doctor diapers he was told and taught over and over that the patient was HIS/HER responsibility, that no one else was responsible.  This persistent culture of responsibility may make it hard for a physician to let go of some control.  But this is totally compounded by NP/PAs who want to come in, see a patient, leave, but not really own the patient. These providers don’t want to be responsible for post discharge care, or decision making.  They want to get in and get out.  If this is you, you get out!

2.  Flabby decision-making: How many times, when faced with a difficult clinical decision, did I  want to immediately reach out to “mom or dad” and have them make a decision?  It’s easy to be lazy, to avoid using the muscles of critical thinking and let the doctor do all the heavy lifting.  Do NOT do this!  You have a brain, you are educated, use both of those tools, actually take time to consider the clinical conundrum.  Of course if after calculated thought a clear course remains foggy, reach out with glee to your attending.  But walk the walk before you talk the talk.

3.  The unspoken agreement: This is where the physician complains that the NP/PA doesn’t “do” what they were hired to do, and the NP/PA states that the physician won’t “let” them do what they were hired to do. Part of this may be a lack of understanding about the appropriate scope of practice for NP/PA provider.  But often, both sides are actually perfectly happy with the NP/PA not actually working within scope of practice.  Change is hard and painful, like giving birth, but when you are finished you have a bouncing, baby, NP/PA practice that will actually advance the care of patients in a positive way.  Start the conversation and the pitocin!

4.  Lack of consistent quality: Easy to say, but not easy to fix. Over and over again I have heard physicians tell me that they like PA/NPs “when they are good,” but that they have seen some bad ones.  Part of this may be related to misunderstanding the needs,  scope of practice and requirements for mentorship of new graduates and novice providers. Part of it also may be lack of quality and consistent programs. Experienced providers need to mentor our newbies and help hospitals and physicians understand the steepness of the learning curve.

5.  Professional development: As an NP/PA provider you are a professional, your work is not just a job, it’s a career! Act like it!  Start developing your career which includes asking, or demanding, the things you want and need from your profession/role, developing your skill set and knowledge base in step with your (hopefully) growing responsibilities, connecting and staying active within your professional organization, advocating for other members of your profession, communicating in a direct and powerful way with your physician colleagues.  You are not a passenger in the canoe of your life. Grab an oar!

Tracy Cardin

Tracy Cardin, ACNP-BC, SFHM is the Associate Director of Clinical Integration at Adfinitas Health and also serves on SHM’s Board of Directors. Prior to this, she was the Director of NP/PA Services for the University of Chicago and worked in private practice for a group of excellent pulmonologists/intensivists for over a decade. She has been a member of SHM for over ten years and has over twenty years of inpatient experience, which seems incredible as she cannot possibly be that old! Her interests include integration of NP/PA providers into hospital medicine groups and communication in difficult situations.

In her free time, she likes to run and lift, read and write and hang out on the front porch of her semi-restored Victorian house with her dear family and friends while drinking a fine glass of red wine and listening to whatever music suits her whimsy.

7 Comments

  1. Brian Wolfe on October 29, 2014 at 10:43 am

    Great Article Tracy. You have raised a lot of interesting points. I have shared this with all of our NP/PA faculty and fellows.

    Thanks,
    Brian

  2. Laura Rosenthal on October 29, 2014 at 1:42 pm

    Thank you, Tracy. Very well said.

  3. David Alden on October 29, 2014 at 3:34 pm

    Well said, indeed!

  4. Kelli Nickols on October 29, 2014 at 6:47 pm

    Tracy great blog! The role of the NP/PA is continuing to expand and our role is to provide our patients with great quality care. Physicians that lack the respect for the roles will ultimately be left in the dark while others get on the bus 🙂

  5. Stephanie Rabe on October 30, 2014 at 7:18 pm

    Very well written, Tracy! I whole-heardedly agree with all of the points you’ve made. Most, if not all of us, have unfortunately experienced the reluctance and restistance of our physician colleagues. With that, you certainly bring up interesting and valid points that our relationships are “two way streets.” I look forward to sharing this with others!

  6. Melissa on October 30, 2014 at 9:38 pm

    One of my instructors in NP school used to say “show me the data.” Well, as Tracy said, the data in this situation is that NPs provide comparable and safe care and outcomes, so it is unfortunate that we have to fight for everything we have. But I think that following Tracy’s advice is a good way to start that fight. As a faculty member in an NP program, I am especially passionate about #4 mentoring new providers. Nurses have been known to “eat their young,” and we all need to be more supportive of one another if we are to flourish as a profession. I would not be where I am today without the support of a fantastic mentor. I was involved in a research project that evaluated role perception and outcomes of an interprofessional clinical experience between our NP students and an all-physician (and med student) inpatient internal medicine service. Prior to working with our students, many of the physicians did not know the NP role or scope of practice. Following their time with our students, they indicated through surveys that they recognized the value that NPs brought to the team, perceived the physician-NP collaborative approach as superior to the physician-only approach, and felt that NPs were more skilled with patient communication and systems issues. There is no question that NPs (and PAs) are here to stay, and I agree that putting ourselves out there, practicing at the top of our game, mentoring our young, and continuing to advance ourselves professionally will go a long way to change the attitude of some of those “villains.” Thanks, Tracy!

  7. Kelly on November 8, 2014 at 11:50 am

    I could not agree more with your summary of some of the key issues that interfere with stable NP practice. I am going to share this as I really believe that identifying barrios is the first step in building successful hospitalist or other collaborative care models. The big winner is the patient, but so are all the providers if we can get over ourselves and truly work as colleagues together!

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